Preview
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
CASCONE & KLUEPFEL
Attorneys at Law
November 6, 2020
JONNA SPILBOR, PLLC
12'h
214 Main Street, floor
Poughkeepsie, New York 12601
Re: Garofolo v. Devi J. Carpenter, et al.
v. The Last Train Stop, Inc.,et al.
Claim No.: LAWC539495-003
Date of Loss: 11/22/14
Our File No.: 05218DZGD
Dear Counselors:
As you are aware, our office represents the third-party defendant The Last Train
Stop, Inc., in the above-named matter. A review of our fileindicates we have not yet
received a response to our Demand for Disclosure as to Medicare/Medicaid Lien
Information nor a response to our discovery demands dated April 2, 2020, copies of
which are attached, including our previous letters requesting your responses.
Kindly provide our office with a response to the aforesaid demand at your earliest
convenience.
Thank you.
Very truly yours,
one A. Potenza
JAP/kis
Enc.
1399 Franidin Avenue, Suite 302, Garden City,NY 11530
p 516.747.1990 f 516.747.1992
cklaw.com
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
CASCONE & KLUEPFEL>a
Argorneys at Ling
Aligust 13, 2020
JONNA SPILBOR, PLLC
214 Main 12*
Street, floor
Poughkeepsie, New York 12601
Re: Garofolo v. Devi J.Carpenter, et al.
v. The Last Train StopJne., et al.
Clahn No.: LAWC539495-003
Date of Loss: I 1/22/14
Our File No.: 05218DZGD
Dear Counselors;
As you are aware. oilr ol'ficerepresents the third-party defendant The Last Ti'ain
Stop, Inc., irithe above-named matter. A review of our file indicates we have not yet
received a response to our Csseñd for Disclosure as to Meditare/Medicaid Lien
Inforrnation dated April 2, 2020, a copy of which is attached for your conicnicñde.
Kindly provide our office with a response to the aforesaid dèmand at your earliest
convenience.
Thank ýou.
Very truly yours,
lo ph A. Potenza
JAP/kis
Enc.
1399 Franldin Avenue, Suite302, Garden City, NY 11530
516.74.7.1990 516.747.1992
CklaW.com
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF DUTCHESS
------------------------------------------ -------X Index No: 2015-52210
KENNETH GAROFOLO and JENNIFER GAROFOLO,
DEMAND FOR
Plaintiff,
DISCLOSURE AS TO
-against- MEDICARE/MEDICAID
LIEN INFORMATION
DEVIN J. CARPENTER, PREFERRED GROUP OF
MANHATTAM, INC. CONSOLIDATED RAIL
CORPORATION and CSX TRANSPORTATION, INC.,
Defendants.
DEVIN J. CARPENTER,
Third-Party Plaintiff,
-against-
THE LAST TRAIN STOP, INC., THE LAST TRAIN STOP,
INC. d/b/a MAMONEY'S IRISH PUB & STEAKHOUSE,
P.O.K. TRAIN STATION, LLC, P.O.K. TRAIN STATION,
LLC d/b/a MAHONEY'S IRISH PUB & STEAKHOUSE and
MAHONEY'S IRISH PUB & STEAKHOUSE.
Third-Party Defendants.
X
C O U N S E L O R S :
PLEASE TAKE NOTICE, that puseant to Article31 of the Civil Practice Law+and Rules.
the üñdciaigned attorney for defendanthereby demands that you furnish us within (30) days of the
service of this notice the following:
1. A ñ=1enst as to whether the plaintilThas received beactits from either Medicare or
Med!déd at any time, for any reason, not limited to theinjuries alleged in theinstant acti‡n.
2. Regardless of vvhether plaintiffreceived said benefits,please state:
a. Plaintiffs date of birth;
b. Plaintiffs Social Security number;
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
c. Plaintiffs resident telephone number;
3. Ifplaintiffdidreceivesaidbcagills,pleasepiúvide:
a. The Medicare/Medicaid identif(cmion nuniber;
b. The Medicarc/Medicaid lilenumber:
c. The address of the öffice the plaintiffs Medicatc/Mcdicaid
handling
tile;
d. Copies. of all decüinents. records, memorandums. notes, etc. in
plaintilTs possession pertaining to plaintifFs receipt of 1cdicare or
Medicaid benefits and/or the existence ofand/or the amount of a lien.
c. A duly executed authorizatipn permitting this finn and/or the
representative of defendant to obtain copies of plaintiffs Mahnirl
or Medicar records (kindly referto theattached forms).
PLEASE TAKE FURTHER NOTICE thatpursuant to CPLR, this is a c ;; demand
and that you are required to serve the d-=ª=3 infanwailuñ the earliest of the us:
by
a. Within 30 days ofthe date of thisdemand:
b. Within 20 days ofreceiving the above-requested information:
c. No laterthan 30 days priorto thecommeñccatent of trial.
If you do not possess the above-requested inf6==àtion, a letter or affidavit to the elTect
should be submitted.
PLEASE TAKE FURTHER NOTICE, that no check can he issued, whe:her after
judg:nent or after settlement, witheat p!nintifPs full e-‡"--:e with the aforementieñed
demanels; and, ifa Mcdic:¡c/Midis:d recipient, until ,±!:±!ff preddes our office with a copy
of the final dessand letter (Mtdicare) and/or a copy of the finallien letter (Medieniti).
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
!
Dated: Garden City, New York
April 2. 2020
Josç h A. Potenza, Esq.
CASCONE & KLUEPFEL, LLP
Attorneysfor Third-Party Dejhiü|<ü i
THE LAST TRAIN STOP, INC.
1399 Franklin Avenue, Suite 302
Gardent City, New York I 1530
(516) 747-1990
Fax: (516) 747-1992
Our File No.f 05218DZGD
TO:
JONNA SPILBOR, PLLC
Attorneysfor Plaintiff
12"'
214 Main Street, floor
Poughkeepsie, New York 12601
(845) 4.85-2529
MAINETTI & MAINETTI, PC.
AttorneysforDefendant/Third-Party Plaintiff
DEVIN J. CARPENTER
130North Front Street. Suite 300
Kingston, New York 12402
(845) 600-0000
LAN·DMAN, CORSl, BALLAINE & FORD, PC
Attorneys for Ddendants
CO.NSOLIDATED RAIL CORPORATION and
CSX TRANSPORTATION, INC.
'
120 Broadway. 27 Eloor
New York, New York 10271
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
NEW YORKSTATE DEPARTNIENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
AU™0R¾ZATION TO RELEASEPROTECTEDMEDICAID MEMBER INFORñATION TO A THIItDPAIITY
MedicaldMember Narne (required)'
Date of Birth (required):
At least.one of the is:|üwing
identificationnumbers.Is
required, both.
prefefeb!y
Client IdanMcation
Number (CIN): Social Security Number
(SSN)
By signing this form,
I unddstandthatI am allowiIng the New York state
Depet=tent of Health
touse or disclose all of
my payment informationas indicated
below. This may Include data on certain
confJ‡n: such as HIV/AIDS, Mental
Health and Alcohol
and 5dbstanceAbuse.
Persons/organizations
cutMiked to:raceive or use.the informn!pn:
Name:
Address:
City-
_,State: 21p:
Phone Nurnber
1. Purpose of the use/dl3dmure:
2. Will the gr:: ;ges;;;
requesting receive financial or In-kind compenset!en
the authorization in exchange focusing
or disclosing the health
!cfermeMendescribed above?Yes No
it. Iunderstand
thatmy health care and the gyrnan:: If I do not sign this form
for my health care will not be affected
except In sorne *™"=when !;f;m.;Ton Is needed for thehealth
plan's eligibility
or enrollment
determ!notions
relating to the individual,
4.| with
understand, few exceptions,
that M
I may see and copy the rtion described on this form if I ask for It, and
that I may get a copy of this form
I sign II.
after
5. I may revoke this auth:::=:;aat the Department
any time by notifying of Healthin at the address below, I ut,
writing
if I do, it will not have any effect took before they received the revocation.If
onsactions Inat the Depaftment not
this authbrihtkh
previously revoked, of this request of one year frorn the date this form
wilt expire upon c::‡:2:ñ
Is signed, whichever
comes first.
.6. I understand
that.this I understand
voluntary.
20thed:±tion.)s the organization
thatif autherizedto receive the
Information
ls.npt a health plan
health .4‡, the released !nformat!on
care gärovideror c:cM..¿‡, may no longer be
protectedby federal
privacy reguktions,and the recipient
therefore data may re-disclose the
of the confidential
confidential
data.
Signatureof Medicaid
Member or Agent Date
If not member,
name of persori signing for member to sign on behalf of member
Authority
to:
Please return MedicaldData ¾/:rchbuss.-
CDits
NYSDOH-EllSCNY
ESP P1-1-1S Dock1
AlbanyNY $2231
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
CMS Medicare
armeraramrmammemsamEr 99Se!!CiarySGTVÌeBS:1 SCC-MEDICARE (rece E33-4227)
TTY/TDD:1-877-486-2048
This form is usedto advise Medicarc of the person or persons yotï have chosen to have access to your
personal health laiblirmtion.
Where to Return Your Completed Authunz.utiuu Forms:
After you complete and sign the authorization form, returnitto.theaddress below:
Medica:re BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS66044
For New York Medicare Bencaciaries ONLY
The New York State Publie Law
l-lealth protects information thatreasonably could identifysé e as
having HIV symptoms or infection.and irilbrrñatiGñregarding a person's contacts. Because ofNeW York's
laws protecthg the privacy of information relatedto alcohol and drug abuse. mental healthtrentmeht, and
HIV. thereare special instmctions forhow you, us a New York resident,should æmp!arc this form.
• ror gtsestien2A, check the box forLingi/ed |,ifa,ü;ü;:a;;
even ifyou want to authorize Medicare
to releaseany and allof your personal health information.
• Then proceed to question 23.
Medicare BCC, Wrl1ten Dept.
Auther!zation
PO Box 1270
Lawrence. KS 66044
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
Instructions for Completing Section 2B of theAuthoriz.disa Form:
Please select one ofthe Jollowing options.
• Option 1 To :i.t:u± all in
hiforiiiation, thespace provided, write: "allinformation, includinÿ
infenuation about alcohol and d rug abuse, mental health treatment, and HIV". Proceed with the rest
of the form.
• Optiori 2 To exclude the infonituticii
listedabove, write "Exclude inlùrmation about alcohol and
HIV"
drug abuse. mental health tr-atment and in thespace provided. You nray also check any ofthe
r hoxes
;,;::;;:;;g and include any additione! in the
!!:::!:::5t:::.: space prmrided. For exampic, you
could write "payment liifariiiation".
Then proceed with the restof the form.
(fyou have any rp"'Mions or need additione! assistence, pleasefeel freeto callus at I-800-MEDICARE
(I-800-633-4227). TTY users should callI-877 486-2048.
Sincerely.
I-800-MEDICARE
Customer Service Representative
Encl.
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
Information to Help You FillOut the
Information"
"l-800-MEDICARE Authorization to Disclose Personal Health Form
By law, Medicare must have your written perniission (an "authorization") to use or give out
your persanal medical information for any purpose that isn tset out in the privacy notice
comained in the Medicare & You handbook, You may take back (-revoke") your wriuen
permission at any time, except if Medicare has already acted based on your permission.
Ifyou want 1-800 MEDICARE to give your personal health information to someone other than
you, you need to letMedicare know in writing.
Ifyou are requesting personal heahh information for a deceased beneticiary, please include a
copy of the legal documentation which indicates your authority to make a request for
example·
information. (For Executor/Executrix papers, next of kin attested by court doct ments
with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a
court stamp and judge's signature. or personal representative papers with a court stamp and
judge's signature.) Also. please explain your relationship to the beneficiary.
Please use this iiistruction sheet when completing your "l-800-MEDICARE
step by step
hifornm*inn"
Authorization to Disclose Personal Health Fonn. Be sure to camp'ete all sections
of the form to ensure timely processing.
1. Print the name of the person with Medicare.
Print the Medicare number as it isshown on the red, white, and blue Medicare
exactly
card. including any letters (for example. 123456789A).
Print the in month, day. and year (mm/dd/yyyy) of the person with Medicare.
birthday
2. This section tells Medicare what personal health information to give out. Please check a
box in 2a to indicate how much information Medicare can disclose. Ifyou only want
Medicare to give out limited informetion ( forexample, Medicare eligibility),also check
the in 2b that to the type of information you want Medicare to give out.
box(es) apply
3. This section tells Medicare when to startand/or when to stop giving out your personal
health information. Check the box that applies and fillin dates. ifnecessary.
4. Medicare will give your personal heahh information to the person(s) or organization(s) you
lillin here. You fillin more than one person or organization, lf you designate an
may
organization. you must one or more individuals in that organization to whom
also.identify
Medicare disclose your personal heahh infonnation.
may
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
5. The person with Medicare or personal representative must sign their name, fillin the date,
and provide the phone number and address of the person with Medicare.
Ifyou are a personal representative of the person with Medicare, check the box. provide
your address and phone number, and attach a copy of the paperwork that shows you can
act for that person (for example. Power of Mtorney).
6. Send your comp!eted, signed authorization to Medicare at the address shown here on our
authorization form.
7. Ifyou change your mind and don't want Medicare to.give out your personal health
information, write to the address shown under númber six on the authorization form and
tell Medicare. Your letterwill revoke your authorization and Medicarc will no longer
give out your personal health information (except for the personal health information
Medicare has already given out based on your permission).
You should make a copy of your signed authorization for your records before mailing itto
Medicare.
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
1-800-MEDICARE Authorization to Disclose Personal Health Information
Use this form ifyou want 1-800-MEDICARE to give your personal health infonnation to
someone other than you.
l. PrintName Medicare Number Date of Birth
(Firstand last
name áf the personwith Niedienre) (Exactlyas shown õn the Medicare Card) (maidd!yyyy)
2. Med;carc will ortly disclose the personal health information you want disclosed.
2A: Check only _qpe box below to.tell Medicare the specific personal health
information you want disclosed:
O Limited information (go to question 26)
O Any information (go to question 3)
2B: Comp!ctc only ifyou selected "limited information". Check all that apply:
O Inforntation about your Medicare eligibility
O information about your Medicare claims
O Information about plan enrollment (e.g.drug or MA Plan)
O Information about pretnium payments
O Other Specific information (please write below; for example, payment information)
3. Check only o_ne box below indicating how long Medicare can use this nuthorization
to disclose your personal health Information (subject to spplicable law-for e ample,
your State may limit how long Medicare may give out your personal health information):
O Disclose my pers.onal health information indefinitely
O Disclose my personal health information for a specified period only
beginning: (mm/dd/yyyy) and endingi(mm/ddlyyyy)
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
4. Fill in the name and address of the or to whom you want
perseg(s) organization(s)
Medicare to disclose your personal health information. Please provide the specific
name of the person(s) for any organization you listbelow:
I. Name:
Address:
2. Name:
Address:
3, Name:
Address:
I authorize 1-800-MEDICARE to disclose my personal health information listed
above to the perscñ(s) or organization(s) 1 have named on this form. I
understand that my personal hen1th informaties may be re-disclõsed by the
person(s) or organization(s) and may no longer be protected by law.
Signature Telephone Number Date vamidatyyyy)
| Print the address of the person with Medicare (Street Address, City, State, and ZIP)
O Check here ifyou are signing as a persunst representative and complete below.
Please attach the appropriate documentation (for example, Power of Attorney).
This o_rily applies if someone otherthan the person with Medicare signed above.
Print the Personal Represcatative's Address (Street Address, City, S.tate, and ZIP)
Telephone Number of Personal Representative;
Personal Representative's Relationship to the Beneficiary:
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
6. Send the completed, signed authorization to:
Meditare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
7. Note:
You have the right to take back ("revoke") your authorization at time, in writh
any g,
except to the extent that Medicare has acted based on your perraission. Ifýou
already
would like to revoke your authurization, send a written request to the address shu n
above.
Your authorization or refusal to authorize disclosure of your personal health
information will have no effect on your enrollment, eligibility for benefits, or the
amount Medicare pays for the health services you receive.
According to the Paperwork Reduction Act of 1995, no persons are required to respoÔd to a
collection of information unless itdisplays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0930. The time required to coteplete
this information collection is estimated to average 15 minutes per response, including the
time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. lf you have corsaients concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security B.oulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
A FF1DAVIT OF SERVICE
STATE OF NEW YORK. )
COUNTY OF NASSAU )ss.:
I,KUILAM L SANCHEZ, being duly sworn, say: I am not a party to the action, am over 18 years
of age and reside at Nassau County, New York:
On June 16, 2020 I served the within DEMAND FOR DISCLOSURID AS TO
MEDICARE/MEDICAID LIEN INFORMATION
[ |Service by by tr:rrh±:g I received un c-moll from glieNek Yurk State li-
the papersby elecunnic speansdimugh thc New York StuteE-File Sptem.
Elecrnmle I'ileSystem indicating timt the tr=::!±::.wns
receivedanddcilvered to all counselin this.action.
Means
|I Service by the papersby electmnic meansthrough emnil addressed
by ±r:yrª±:;; to theattomcyscuford: onerutschnarneduelo COVID.19.
Electninic
Mcuns
IX| Service by by depusiting u true copy thereof in a post-paid wrapper, in urrunicial depository underthu excitisive cure ttnd oDielul d¾positoryunderlity
Mall Service widiin the New York 51ste.uddressedto cach of duc following personsat the let
exclusive cure and custody of the U.s. IWtal
known.addresssetforth nAcr eachname:
|1 Per>unal by delivering a trug copy thereof personn1lyto eachpersonniunedhelow at theaddressindicated. I knew cuch personservedto bethepersun
Served an i•WA und described in spid pupersataparlythereus:
indMd;;;;:
| | Overnight into the custody or UNITIfD
hy dùpositing a töte cüpy therenT,enchised in u wrapper Itddressedng shomrbelow. rur
PANClil. sliRVICli
ovemight delivery. prior to the latest thne designatedby the servico forovernight delivery.
TO:
.IONNA SPILBOR. PLLC
Auorneys for Plaintiff
I2'h
214 Main Street, floor
Poughkeepsic, New York 12601
(845) 485-2529
MAINETTI & MAINETTl, PC.
Attorneys for Defendant/Third-Party Plaintiff
DEVIN J. CARPENTER
130North Front Street,Suite 300
Kingston, New York I2402
(845) 600-0000
KUlbA L SANC.
Sworn to beforeme this
I6d'
dayofJune, 2020
otury Pu se c sati
b.ic. 61 N GW VOrk
.Ntra.
No. 01MC62fi0790
Commis:üOn ines Novomoer 7, 20
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
INDEX NO.; 52210/2015
SUPREME COURTpF T STATE OF NEW YORK
COUNTY OF DUTCHESS
KENBET I GI Q ang¤nNNIFER
GAROFOlso
Plaintïff
-argainst -
DEVIN J. CARPENTER, PÄEF RRED GROUP ÖF
MANHATTAN, INCGCONSOLIDATED RAIL
CORPORATION and CSX TRANSPÔRTATION,
INC.,
Defenitants.
And Tlstrd-PartyAction
DEMAN#fQR DISCLQSURE S TO
MEDICARE/MEDICEID LIEN INFORMÂTION
CASCONE & KLUEPFEL, LLP.
Attorneysfor Thi Rarty D fc::¼!a::tTHE LaiST TRAIN
STOP, INC. Office undPost Office Address, Telephone
f3991ranklin Avenue
Suite 302
Garden City, New York11530
(516) 747-1990
(516) 7#7-1992 Firestinfle
To:ALL.COUNSEL
ifths)Wthli
SeWicelornicirpy
is hereby admi¼ted.
outeL
Attorneyp)for TNrd-PartyDercedant
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210
NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022
CASCONE &. KLUEPFEL=
Attorneys at Law
August 11, 202Ö
JONNA SPILBOR, PLLC
12d'
214 Main Street, floor
Poughkeepsie. New York 12601
MAINETTI & MAINETTI, PC.
130North Front Street, Suite 300
Kingston, New York 12402
Re: Garofolo v. Devi J. Carpenter, et al.
v- The Last Train Stop, et at
Claim No.: LAWd539495-003
Date of Loss: 11722/14
Our File No.: 05218DZGD
Dear Counselors:
As you are aware, our office reprësents the third-party deendant The Last Train
Stop, inc., in the above-named matter. A review of our file indicates we have not yet
received a i¢spurise to our combined discovery dcmañds dated April 2. 2020. copies of
which are enclosed for your conveiiiciice. Kindly provide our office with response
Preview
FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 CASCONE & KLUEPFEL Attorneys at Law November 6, 2020 JONNA SPILBOR, PLLC 12'h 214 Main Street, floor Poughkeepsie, New York 12601 Re: Garofolo v. Devi J. Carpenter, et al. v. The Last Train Stop, Inc.,et al. Claim No.: LAWC539495-003 Date of Loss: 11/22/14 Our File No.: 05218DZGD Dear Counselors: As you are aware, our office represents the third-party defendant The Last Train Stop, Inc., in the above-named matter. A review of our fileindicates we have not yet received a response to our Demand for Disclosure as to Medicare/Medicaid Lien Information nor a response to our discovery demands dated April 2, 2020, copies of which are attached, including our previous letters requesting your responses. Kindly provide our office with a response to the aforesaid demand at your earliest convenience. Thank you. Very truly yours, one A. Potenza JAP/kis Enc. 1399 Franidin Avenue, Suite 302, Garden City,NY 11530 p 516.747.1990 f 516.747.1992 cklaw.com FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 CASCONE & KLUEPFEL>a Argorneys at Ling Aligust 13, 2020 JONNA SPILBOR, PLLC 214 Main 12* Street, floor Poughkeepsie, New York 12601 Re: Garofolo v. Devi J.Carpenter, et al. v. The Last Train StopJne., et al. Clahn No.: LAWC539495-003 Date of Loss: I 1/22/14 Our File No.: 05218DZGD Dear Counselors; As you are aware. oilr ol'ficerepresents the third-party defendant The Last Ti'ain Stop, Inc., irithe above-named matter. A review of our file indicates we have not yet received a response to our Csseñd for Disclosure as to Meditare/Medicaid Lien Inforrnation dated April 2, 2020, a copy of which is attached for your conicnicñde. Kindly provide our office with a response to the aforesaid dèmand at your earliest convenience. Thank ýou. Very truly yours, lo ph A. Potenza JAP/kis Enc. 1399 Franldin Avenue, Suite302, Garden City, NY 11530 516.74.7.1990 516.747.1992 CklaW.com FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF DUTCHESS ------------------------------------------ -------X Index No: 2015-52210 KENNETH GAROFOLO and JENNIFER GAROFOLO, DEMAND FOR Plaintiff, DISCLOSURE AS TO -against- MEDICARE/MEDICAID LIEN INFORMATION DEVIN J. CARPENTER, PREFERRED GROUP OF MANHATTAM, INC. CONSOLIDATED RAIL CORPORATION and CSX TRANSPORTATION, INC., Defendants. DEVIN J. CARPENTER, Third-Party Plaintiff, -against- THE LAST TRAIN STOP, INC., THE LAST TRAIN STOP, INC. d/b/a MAMONEY'S IRISH PUB & STEAKHOUSE, P.O.K. TRAIN STATION, LLC, P.O.K. TRAIN STATION, LLC d/b/a MAHONEY'S IRISH PUB & STEAKHOUSE and MAHONEY'S IRISH PUB & STEAKHOUSE. Third-Party Defendants. X C O U N S E L O R S : PLEASE TAKE NOTICE, that puseant to Article31 of the Civil Practice Law+and Rules. the üñdciaigned attorney for defendanthereby demands that you furnish us within (30) days of the service of this notice the following: 1. A ñ=1enst as to whether the plaintilThas received beactits from either Medicare or Med!déd at any time, for any reason, not limited to theinjuries alleged in theinstant acti‡n. 2. Regardless of vvhether plaintiffreceived said benefits,please state: a. Plaintiffs date of birth; b. Plaintiffs Social Security number; FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 c. Plaintiffs resident telephone number; 3. Ifplaintiffdidreceivesaidbcagills,pleasepiúvide: a. The Medicare/Medicaid identif(cmion nuniber; b. The Medicarc/Medicaid lilenumber: c. The address of the öffice the plaintiffs Medicatc/Mcdicaid handling tile; d. Copies. of all decüinents. records, memorandums. notes, etc. in plaintilTs possession pertaining to plaintifFs receipt of 1cdicare or Medicaid benefits and/or the existence ofand/or the amount of a lien. c. A duly executed authorizatipn permitting this finn and/or the representative of defendant to obtain copies of plaintiffs Mahnirl or Medicar records (kindly referto theattached forms). PLEASE TAKE FURTHER NOTICE thatpursuant to CPLR, this is a c ;; demand and that you are required to serve the d-=ª=3 infanwailuñ the earliest of the us: by a. Within 30 days ofthe date of thisdemand: b. Within 20 days ofreceiving the above-requested information: c. No laterthan 30 days priorto thecommeñccatent of trial. If you do not possess the above-requested inf6==àtion, a letter or affidavit to the elTect should be submitted. PLEASE TAKE FURTHER NOTICE, that no check can he issued, whe:her after judg:nent or after settlement, witheat p!nintifPs full e-‡"--:e with the aforementieñed demanels; and, ifa Mcdic:¡c/Midis:d recipient, until ,±!:±!ff preddes our office with a copy of the final dessand letter (Mtdicare) and/or a copy of the finallien letter (Medieniti). FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 ! Dated: Garden City, New York April 2. 2020 Josç h A. Potenza, Esq. CASCONE & KLUEPFEL, LLP Attorneysfor Third-Party Dejhiü|<ü i THE LAST TRAIN STOP, INC. 1399 Franklin Avenue, Suite 302 Gardent City, New York I 1530 (516) 747-1990 Fax: (516) 747-1992 Our File No.f 05218DZGD TO: JONNA SPILBOR, PLLC Attorneysfor Plaintiff 12"' 214 Main Street, floor Poughkeepsie, New York 12601 (845) 4.85-2529 MAINETTI & MAINETTI, PC. AttorneysforDefendant/Third-Party Plaintiff DEVIN J. CARPENTER 130North Front Street. Suite 300 Kingston, New York 12402 (845) 600-0000 LAN·DMAN, CORSl, BALLAINE & FORD, PC Attorneys for Ddendants CO.NSOLIDATED RAIL CORPORATION and CSX TRANSPORTATION, INC. ' 120 Broadway. 27 Eloor New York, New York 10271 FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 NEW YORKSTATE DEPARTNIENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS AU™0R¾ZATION TO RELEASEPROTECTEDMEDICAID MEMBER INFORñATION TO A THIItDPAIITY MedicaldMember Narne (required)' Date of Birth (required): At least.one of the is:|üwing identificationnumbers.Is required, both. prefefeb!y Client IdanMcation Number (CIN): Social Security Number (SSN) By signing this form, I unddstandthatI am allowiIng the New York state Depet=tent of Health touse or disclose all of my payment informationas indicated below. This may Include data on certain confJ‡n: such as HIV/AIDS, Mental Health and Alcohol and 5dbstanceAbuse. Persons/organizations cutMiked to:raceive or use.the informn!pn: Name: Address: City- _,State: 21p: Phone Nurnber 1. Purpose of the use/dl3dmure: 2. Will the gr:: ;ges;;; requesting receive financial or In-kind compenset!en the authorization in exchange focusing or disclosing the health !cfermeMendescribed above?Yes No it. Iunderstand thatmy health care and the gyrnan:: If I do not sign this form for my health care will not be affected except In sorne *™"=when !;f;m.;Ton Is needed for thehealth plan's eligibility or enrollment determ!notions relating to the individual, 4.| with understand, few exceptions, that M I may see and copy the rtion described on this form if I ask for It, and that I may get a copy of this form I sign II. after 5. I may revoke this auth:::=:;aat the Department any time by notifying of Healthin at the address below, I ut, writing if I do, it will not have any effect took before they received the revocation.If onsactions Inat the Depaftment not this authbrihtkh previously revoked, of this request of one year frorn the date this form wilt expire upon c::‡:2:ñ Is signed, whichever comes first. .6. I understand that.this I understand voluntary. 20thed:±tion.)s the organization thatif autherizedto receive the Information ls.npt a health plan health .4‡, the released !nformat!on care gärovideror c:cM..¿‡, may no longer be protectedby federal privacy reguktions,and the recipient therefore data may re-disclose the of the confidential confidential data. Signatureof Medicaid Member or Agent Date If not member, name of persori signing for member to sign on behalf of member Authority to: Please return MedicaldData ¾/:rchbuss.- CDits NYSDOH-EllSCNY ESP P1-1-1S Dock1 AlbanyNY $2231 FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 CMS Medicare armeraramrmammemsamEr 99Se!!CiarySGTVÌeBS:1 SCC-MEDICARE (rece E33-4227) TTY/TDD:1-877-486-2048 This form is usedto advise Medicarc of the person or persons yotï have chosen to have access to your personal health laiblirmtion. Where to Return Your Completed Authunz.utiuu Forms: After you complete and sign the authorization form, returnitto.theaddress below: Medica:re BCC, Written Authorization Dept. PO Box 1270 Lawrence, KS66044 For New York Medicare Bencaciaries ONLY The New York State Publie Law l-lealth protects information thatreasonably could identifysé e as having HIV symptoms or infection.and irilbrrñatiGñregarding a person's contacts. Because ofNeW York's laws protecthg the privacy of information relatedto alcohol and drug abuse. mental healthtrentmeht, and HIV. thereare special instmctions forhow you, us a New York resident,should æmp!arc this form. • ror gtsestien2A, check the box forLingi/ed |,ifa,ü;ü;:a;; even ifyou want to authorize Medicare to releaseany and allof your personal health information. • Then proceed to question 23. Medicare BCC, Wrl1ten Dept. Auther!zation PO Box 1270 Lawrence. KS 66044 FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 Instructions for Completing Section 2B of theAuthoriz.disa Form: Please select one ofthe Jollowing options. • Option 1 To :i.t:u± all in hiforiiiation, thespace provided, write: "allinformation, includinÿ infenuation about alcohol and d rug abuse, mental health treatment, and HIV". Proceed with the rest of the form. • Optiori 2 To exclude the infonituticii listedabove, write "Exclude inlùrmation about alcohol and HIV" drug abuse. mental health tr-atment and in thespace provided. You nray also check any ofthe r hoxes ;,;::;;:;;g and include any additione! in the !!:::!:::5t:::.: space prmrided. For exampic, you could write "payment liifariiiation". Then proceed with the restof the form. (fyou have any rp"'Mions or need additione! assistence, pleasefeel freeto callus at I-800-MEDICARE (I-800-633-4227). TTY users should callI-877 486-2048. Sincerely. I-800-MEDICARE Customer Service Representative Encl. FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 Information to Help You FillOut the Information" "l-800-MEDICARE Authorization to Disclose Personal Health Form By law, Medicare must have your written perniission (an "authorization") to use or give out your persanal medical information for any purpose that isn tset out in the privacy notice comained in the Medicare & You handbook, You may take back (-revoke") your wriuen permission at any time, except if Medicare has already acted based on your permission. Ifyou want 1-800 MEDICARE to give your personal health information to someone other than you, you need to letMedicare know in writing. Ifyou are requesting personal heahh information for a deceased beneticiary, please include a copy of the legal documentation which indicates your authority to make a request for example· information. (For Executor/Executrix papers, next of kin attested by court doct ments with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a court stamp and judge's signature. or personal representative papers with a court stamp and judge's signature.) Also. please explain your relationship to the beneficiary. Please use this iiistruction sheet when completing your "l-800-MEDICARE step by step hifornm*inn" Authorization to Disclose Personal Health Fonn. Be sure to camp'ete all sections of the form to ensure timely processing. 1. Print the name of the person with Medicare. Print the Medicare number as it isshown on the red, white, and blue Medicare exactly card. including any letters (for example. 123456789A). Print the in month, day. and year (mm/dd/yyyy) of the person with Medicare. birthday 2. This section tells Medicare what personal health information to give out. Please check a box in 2a to indicate how much information Medicare can disclose. Ifyou only want Medicare to give out limited informetion ( forexample, Medicare eligibility),also check the in 2b that to the type of information you want Medicare to give out. box(es) apply 3. This section tells Medicare when to startand/or when to stop giving out your personal health information. Check the box that applies and fillin dates. ifnecessary. 4. Medicare will give your personal heahh information to the person(s) or organization(s) you lillin here. You fillin more than one person or organization, lf you designate an may organization. you must one or more individuals in that organization to whom also.identify Medicare disclose your personal heahh infonnation. may FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 5. The person with Medicare or personal representative must sign their name, fillin the date, and provide the phone number and address of the person with Medicare. Ifyou are a personal representative of the person with Medicare, check the box. provide your address and phone number, and attach a copy of the paperwork that shows you can act for that person (for example. Power of Mtorney). 6. Send your comp!eted, signed authorization to Medicare at the address shown here on our authorization form. 7. Ifyou change your mind and don't want Medicare to.give out your personal health information, write to the address shown under númber six on the authorization form and tell Medicare. Your letterwill revoke your authorization and Medicarc will no longer give out your personal health information (except for the personal health information Medicare has already given out based on your permission). You should make a copy of your signed authorization for your records before mailing itto Medicare. FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 1-800-MEDICARE Authorization to Disclose Personal Health Information Use this form ifyou want 1-800-MEDICARE to give your personal health infonnation to someone other than you. l. PrintName Medicare Number Date of Birth (Firstand last name áf the personwith Niedienre) (Exactlyas shown õn the Medicare Card) (maidd!yyyy) 2. Med;carc will ortly disclose the personal health information you want disclosed. 2A: Check only _qpe box below to.tell Medicare the specific personal health information you want disclosed: O Limited information (go to question 26) O Any information (go to question 3) 2B: Comp!ctc only ifyou selected "limited information". Check all that apply: O Inforntation about your Medicare eligibility O information about your Medicare claims O Information about plan enrollment (e.g.drug or MA Plan) O Information about pretnium payments O Other Specific information (please write below; for example, payment information) 3. Check only o_ne box below indicating how long Medicare can use this nuthorization to disclose your personal health Information (subject to spplicable law-for e ample, your State may limit how long Medicare may give out your personal health information): O Disclose my pers.onal health information indefinitely O Disclose my personal health information for a specified period only beginning: (mm/dd/yyyy) and endingi(mm/ddlyyyy) FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 4. Fill in the name and address of the or to whom you want perseg(s) organization(s) Medicare to disclose your personal health information. Please provide the specific name of the person(s) for any organization you listbelow: I. Name: Address: 2. Name: Address: 3, Name: Address: I authorize 1-800-MEDICARE to disclose my personal health information listed above to the perscñ(s) or organization(s) 1 have named on this form. I understand that my personal hen1th informaties may be re-disclõsed by the person(s) or organization(s) and may no longer be protected by law. Signature Telephone Number Date vamidatyyyy) | Print the address of the person with Medicare (Street Address, City, State, and ZIP) O Check here ifyou are signing as a persunst representative and complete below. Please attach the appropriate documentation (for example, Power of Attorney). This o_rily applies if someone otherthan the person with Medicare signed above. Print the Personal Represcatative's Address (Street Address, City, S.tate, and ZIP) Telephone Number of Personal Representative; Personal Representative's Relationship to the Beneficiary: FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 6. Send the completed, signed authorization to: Meditare BCC, Written Authorization Dept. PO Box 1270 Lawrence, KS 66044 7. Note: You have the right to take back ("revoke") your authorization at time, in writh any g, except to the extent that Medicare has acted based on your perraission. Ifýou already would like to revoke your authurization, send a written request to the address shu n above. Your authorization or refusal to authorize disclosure of your personal health information will have no effect on your enrollment, eligibility for benefits, or the amount Medicare pays for the health services you receive. According to the Paperwork Reduction Act of 1995, no persons are required to respoÔd to a collection of information unless itdisplays a valid OMB control number. The valid OMB control number for this information collection is 0938-0930. The time required to coteplete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. lf you have corsaients concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security B.oulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 A FF1DAVIT OF SERVICE STATE OF NEW YORK. ) COUNTY OF NASSAU )ss.: I,KUILAM L SANCHEZ, being duly sworn, say: I am not a party to the action, am over 18 years of age and reside at Nassau County, New York: On June 16, 2020 I served the within DEMAND FOR DISCLOSURID AS TO MEDICARE/MEDICAID LIEN INFORMATION [ |Service by by tr:rrh±:g I received un c-moll from glieNek Yurk State li- the papersby elecunnic speansdimugh thc New York StuteE-File Sptem. Elecrnmle I'ileSystem indicating timt the tr=::!±::.wns receivedanddcilvered to all counselin this.action. Means |I Service by the papersby electmnic meansthrough emnil addressed by ±r:yrª±:;; to theattomcyscuford: onerutschnarneduelo COVID.19. Electninic Mcuns IX| Service by by depusiting u true copy thereof in a post-paid wrapper, in urrunicial depository underthu excitisive cure ttnd oDielul d¾positoryunderlity Mall Service widiin the New York 51ste.uddressedto cach of duc following personsat the let exclusive cure and custody of the U.s. IWtal known.addresssetforth nAcr eachname: |1 Per>unal by delivering a trug copy thereof personn1lyto eachpersonniunedhelow at theaddressindicated. I knew cuch personservedto bethepersun Served an i•WA und described in spid pupersataparlythereus: indMd;;;;: | | Overnight into the custody or UNITIfD hy dùpositing a töte cüpy therenT,enchised in u wrapper Itddressedng shomrbelow. rur PANClil. sliRVICli ovemight delivery. prior to the latest thne designatedby the servico forovernight delivery. TO: .IONNA SPILBOR. PLLC Auorneys for Plaintiff I2'h 214 Main Street, floor Poughkeepsic, New York 12601 (845) 485-2529 MAINETTI & MAINETTl, PC. Attorneys for Defendant/Third-Party Plaintiff DEVIN J. CARPENTER 130North Front Street,Suite 300 Kingston, New York I2402 (845) 600-0000 KUlbA L SANC. Sworn to beforeme this I6d' dayofJune, 2020 otury Pu se c sati b.ic. 61 N GW VOrk .Ntra. No. 01MC62fi0790 Commis:üOn ines Novomoer 7, 20 FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 INDEX NO.; 52210/2015 SUPREME COURTpF T STATE OF NEW YORK COUNTY OF DUTCHESS KENBET I GI Q ang¤nNNIFER GAROFOlso Plaintïff -argainst - DEVIN J. CARPENTER, PÄEF RRED GROUP ÖF MANHATTAN, INCGCONSOLIDATED RAIL CORPORATION and CSX TRANSPÔRTATION, INC., Defenitants. And Tlstrd-PartyAction DEMAN#fQR DISCLQSURE S TO MEDICARE/MEDICEID LIEN INFORMÂTION CASCONE & KLUEPFEL, LLP. Attorneysfor Thi Rarty D fc::¼!a::tTHE LaiST TRAIN STOP, INC. Office undPost Office Address, Telephone f3991ranklin Avenue Suite 302 Garden City, New York11530 (516) 747-1990 (516) 7#7-1992 Firestinfle To:ALL.COUNSEL ifths)Wthli SeWicelornicirpy is hereby admi¼ted. outeL Attorneyp)for TNrd-PartyDercedant FILED: DUTCHESS COUNTY CLERK 03/03/2022 09:55 AM INDEX NO. 2015-52210 NYSCEF DOC. NO. 61 RECEIVED NYSCEF: 03/03/2022 CASCONE &. KLUEPFEL= Attorneys at Law August 11, 202Ö JONNA SPILBOR, PLLC 12d' 214 Main Street, floor Poughkeepsie. New York 12601 MAINETTI & MAINETTI, PC. 130North Front Street, Suite 300 Kingston, New York 12402 Re: Garofolo v. Devi J. Carpenter, et al. v- The Last Train Stop, et at Claim No.: LAWd539495-003 Date of Loss: 11722/14 Our File No.: 05218DZGD Dear Counselors: As you are aware, our office reprësents the third-party deendant The Last Train Stop, inc., in the above-named matter. A review of our file indicates we have not yet received a i¢spurise to our combined discovery dcmañds dated April 2. 2020. copies of which are enclosed for your conveiiiciice. Kindly provide our office with response